DSM-5: NP0043 – Session 1

The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is coming, are you prepared? Have you asked yourself ‘As a therapist how will this affect my practice? My clients?’ Join Allen Frances as he explains the major differences between DSM-IV and DSM-5 and how you can improve your psychiatric diagnosis.

Allen Frances On Why DSM-5’s New Diagnoses Are Problematic

Learn how to sidestep common clinical mistakes that promote resistance, and ways to overcome resistance if it does occur. Professor and author of Effective Techniques for Dealing with Highly Resistant Clients, Clifton Mitchell describes the best approaches to circumvent resistance, from clarifying goals, slowing down the pace, and helping clients find emotionally compelling reasons to change.

Explore a treatment plan for clients with narcissistic personality disorder that helps you maintain compassion while achieving leverage. Wendy Behary, author of Disarming the Narcissist: Surviving and Thriving with the Self-Absorbed, teaches how to use tactical confrontation, cognitive restructuring, behavioral therapy and skills training, experiential psychotherapy, and more.

How do you work with borderline personality disorder clients without lapsing into feelings of defensiveness? Richard Schwartz, originator of the Internal Family Systems model, describes working with borderline personality disorder clients who are preoccupied with protecting their vulnerable inner “parts” and can respond to mental health treatment with anger, impulsiveness, and aggressiveness.

Discover how to join with self-loathing clients who are so filled with feelings of shame and worthlessness that they find little benefit from the therapeutic relationship. Janina Fisher, who lectures and writes about integrating neuroscience research and body-centered approaches into psychotherapy, guides the viewer on how to help clients heal their attachment issues and gain self-compassion and acceptance.

In this session, marriage and family therapist William Doherty highlights some techniques to follow when a client isn’t following the treatment plan, continues to follow a self-destructive path, or simply isn’t making progress. Learn how to avoid sounding like a disappointed parent or threatening to abandon the client when therapy stalls.

Discover an assessment protocol to identify six personal characteristics that’ll allow you to customize treatment to match clients’ needs. Distinguished professor of psychology and clinical psychologist John Norcross explores how to identify these personal characteristics to achieve more effective treatment.

Stephen Porges on a Popular Neuroscientific Misconception

Gary Greenberg On The Role Of Economic Factors In The DSM

Creating useful constructs that enable clinicians to communicate more effectively is the intended purpose of the Diagnostic & Statistical Manual. The reality is that by giving diagnostic criteria and a name to a specific human suffering, an entry in the DSM increases the likelihood of research and treatment dollars going to that condition. Read more …

How to Help Learning Stick for Clients

By Tori Rodriguez

It’s usually easy to see when clients are tuned out or turned off, simply not absorbing what you’re trying to get across. What’s puzzling is when things seem to be really clicking in session—when you’re sure clients will return to report their success at having applied the new awareness and skills they’ve just acquired to their lives—and then you find that they haven’t followed through.

A study by David Atkins and colleagues, published in the June 2012 issue of Behaviour Research & Therapy, found that clients in couples therapy are less likely to recall communication skills learned during high levels of emotional arousal. As the authors report, “Greater emotional arousal predicts remembering fewer skills,” and “sustained emotional arousal may impact memory through encoding, retrieval, or both.” Other studies have also established how strongly stress hormones can affect learning and memory. However, in the June 2013 issue of Couple and Family Psychology: Research and Practice, couples therapist Brent Atkinson offers some practical suggestions for addressing this obstacle to therapeutic change. He proposes that combining our emerging understanding of brain science with the power of deliberate practice gives us effective tools for mitigating the power of emotionally charged situations. Keeping emotions in check would then prevent clients from losing access to the insights and skills they’ve presumably acquired in the consulting room.

“Many clients don’t have a basic level of mental fitness required to make changes,” says Atkinson. For these clients, despite their best intentions, being in conflicts with their partner or in other triggering circumstances results in flooding, or becoming overwhelmed by negative emotions. This often triggers diffuse physiological arousal (DPA)—activation of the autonomic nervous system’s alarm response, which initiates changes like increased heart rate, blood pressure, and levels of stress hormones like cortisol, all of which help prepare the body to deal with threats. In spite of the new insights and skills explored in therapy, the chance of new responses being tried out when a client’s nervous system has been hijacked by DPA are radically diminished. So before clients can make changes in their relationship with a partner, before therapy can really begin to have any real impact, the first order of business is to change clients’ relationship with their nervous system.

In Atkinson’s treatment model, the therapist first works with clients to get them motivated to tune up their nervous system, helping them understand why it’s important and introducing them to the concept of mindfulness. The couples then participate in an eight-week mindfulness course, and during concurrent couples therapy sessions, they practice extending the skills they’re learning to their relationships. If clients need help mindfully responding during stressful partner interactions, they listen to their partner’s criticisms via prerecorded voice messages, during which they practice using mindfulness skills to turn down their physiological and emotional arousal. As clients become more skilled at self-soothing, the therapist helps them to identify their typical sequence of conflict and to mentally rehearse how to respond more effectively when conflict arises—much like how athletes or musicians might engage in mental practice to enhance their skills.

Treatment models like Atkinson’s move the field of therapy away from a faith in the magical power of insight, or even the generalized benefits of the therapeutic alliance, toward a closer look at how to concretely make the process of emotional learning more efficient and sustainable. Since therapy outcome studies consistently show a discouraging overall finding—the average results of psychotherapy haven’t improved over the last 50 years—this new research certainly seems to be a step in the right direction.

Talking on the Edge

Assessing the risk of suicide

By Douglas Flemons

Q:I feel unprepared to make a proper suicide assessment with my clients. I’m nervous that I’ll neglect to ask, or the client won’t tell me, something vital to making the right clinical decision. Can you recommend an objective measure for reliably determining suicidality?

A: Suicide assessment is a high-stakes process infused with uncertainty, so your desire to find an assessment instrument to help with your decision-making is understandable. However, even the best scales can be unreliable when they’re completed in the midst of an emotional crisis. Thus, rather than outsourcing your decision-making to an instrument, I recommend that you learn how to conduct a conversational evaluation that builds on your therapeutic skills. While most clinicians already know to ask whether a client has an intent to die, a suicide plan, or access to a means for carrying it out, it’s important to go beyond simply posing these questions to get a fuller picture of the client’s risk of suicide.

Effective suicide assessments are built on a foundation of empathic connection. When clients feel heard, understood, and respected, they’re likelier to let down their guard and explore sensitive topics. In broaching such topics, the best way to protect them from feeling grilled is to intersperse your questions with empathic statements, such as “Sometimes your obligations feel impossible to meet,” or “It sounds exhausting to have to fend off intrusive thoughts of taking your life all the time.”

To help guide your assessment dialogue, my colleague, psychiatrist Len Gralnik, and I have identified four broad categories of inquiry:

Disruptions and demands—such as the loss of a relationship or social and financial status, overwhelming expectations and obligations, legal entanglements, and instances of abuse, bullying, or other traumas.

Troubling behaviors—those that increase the danger of a client’s situation, such as withdrawing from activities and other people, engaging in substance abuse or disordered eating, acting impulsively or compulsively, and harming oneself or others.

Desperation—which encompasses many of the most urgent indicators for concern, such as hopelessness, an intense desire for relief, an intent to die, a plan for making a suicide attempt, a history of making one or more attempts, or making preparations for a future attempt.

To get a deeper sense of whether clients are in imminent danger of making a suicide attempt, you must obtain a clear view not only of the likelihood that they’ll act on their desperation, but also of their resources for making it through the crisis. To this end, you’ll want to explore intra- and interpersonal sources of resilience, protective beliefs, exceptions to problems, past successes, current skills, and effective strategies for dealing with stressors. For example, I once saw a former college football player whose game-hardened ability to keep moving forward, regardless of injuries and pain, served as a source of resilience when he felt like succumbing to suicidal thoughts. Also, some of my deeply religious clients have been protected by their faith’s prohibitions against suicide. I can almost always find some degree of variation in my clients’ desperation. If there are times when they feel more overwhelmed and depressed, that means there are times when they feel less so.

However, when you make note of your clients’ resources, take care not to appear overly impressed by their resilience or the support that’s available to them. To them, life is hopeless, so straightforward optimism on your part will likely be slapped away as irritating naivety. Instead, it’s helpful to adopt a casual manner when making resource-based inquiries and noting any positive discoveries. For example, you could say to my client who’d played football, “So when you were playing college ball, you didn’t let the pain slow you down? Have you always had that kind of strength and determination, or was it something you learned? How’s that coming into play these days?”

Some clinicians routinely use boilerplate no-harm or no-suicide contracts, hoping to secure a troubled client’s commitment to live and lessen their own legal exposure if the client were to end up completing suicide. Research has shown, however, that signing such contracts doesn’t afford the client any added protection; and when sued, clinicians who use contracts don’t fare any better in the courtroom.

Instead of no-harm or no-suicide contracts, I prefer working with clients to construct a uniquely relevant safety plan, a resource-based to-do list that identifies protective steps the client and his or her significant others are willing and able to undertake.

In developing the safety plan together, first decide how the client and significant others can restrict access to all possible means for attempting suicide. You can also explore reasonable alternatives to troubling behaviors for coping with distress and identify safe havens the client could access for a limited time if necessary. Write down the contact information for anyone who could offer a safe haven or other forms of support.

I once consulted on a case involving a young suicidal woman, Michelle, who had persistent thoughts of jumping off the balcony of her 11th-story apartment. Although her parents weren’t available to help, Michelle said she had a good friend, Vanessa, who lived on the ground floor of the same building. I arranged for Vanessa to come into our session, and the three of us worked out details of a safety plan. We decided that whenever the thoughts of jumping ramped up, Michelle would first go to her walk-in closet, which she considered a safe haven. Once there, she’d meditate and, if necessary, call the numbers of family, friends, and professional resources that we wrote down. If these measures didn’t feel safe enough, she’d take the elevator down to Vanessa’s, and—with the key that Vanessa said she’d give her once they got home—let herself in. Michelle didn’t consider or worry about any other methods of dying, so the measures necessary for keeping her relatively safe were fairly straightforward.

A safety plan is designed as a temporary measure to get suicidal clients through distressing times, so you need to make sure the plan is reasonable and doable. A plan that’s too elaborate or demanding isn’t safe. In addition to significant others, you and the client should consider enlisting his or her work supervisors or school administrators to alter the client’s schedule, reduce his or her workload, or grant a leave of absence. Also, determine whether the client would consider initiating, resuming, or continuing relevant therapy or treatment. In addition to generating a list of personal and professional contacts the client could call if necessary, identify emergency contacts such as crisis lines and nearby hospitals. Once the safety plan is complete, make a copy for your file and give the original to the client.

If the client appears to be at imminent risk of making a suicide attempt and a safety plan doesn’t seem feasible or sufficient to keep him or her safe, then you’ll need to arrange transportation to a psychiatric receiving facility for evaluation and possible involuntary admission. But never make this choice simply to be on the safe side. Sending someone to the hospital who’s depressed but not suicidal, for example, may alleviate your immediate anxiety, but it may cause the client to avoid seeking out mental health treatment in the future.

Arrive at your safety decision by piecing together all the information you gather throughout the assessment: what the client tells you, what you empathically glean, and what you know from the professional literature about risks and resources. Whenever possible, consult with a colleague or supervisor, so you can compare your perspectives.
Once you make a decision, give yourself the opportunity to take a second look at it, along with the data informing it. If, upon considering everything a second time, you come to the same conclusion, then you can proceed with added confidence. If you end up with second thoughts, listen to your doubts and use them to prompt further information gathering.

It isn’t unusual for me during an assessment to change my mind several times about whether a safety plan can be a viable option for keeping a client alive. Much of what Michelle told me—about her depression, thoughts about jumping, absence of family—pointed to hospitalization as the best choice for keeping her safe. But glimmers of hope kept appearing, so I kept asking questions, and together we finally determined that she had the necessary resources to stay safe—and we were right. She told me much later, when the crisis had passed, that she’d pinned up her safety plan inside her walk-in closet and would go in there and read it as a source of reassurance and inspiration.

Ultimately, suicide assessments are inherently anxiety-provoking and emotionally taxing, even when they go well and the client can safely negotiate harrowing desires, thoughts, and circumstances. Following an assessment, it helps to secure time with colleagues to talk through how the client presented, what you were able to discover, what you decided, how the client responded to the process as a whole, and what you were experiencing throughout the process. Taking care of yourself in this way will help you feel better prepared the next time.

Douglas Flemons, PhD, is Professor of Family Therapy and Clinical Professor of Family Medicine at Nova Southeastern University. He’s coauthor of Relational Suicide Assessment, author of Of One Mind, and coeditor of Quickies: The Handbook of Brief Sex Therapy. He offers workshops on suicide assessment, hypnosis, and brief therapy. Contact: douglas@nova.edu.

Evoking the Inner Artist

How to replace pathology with creativity

By Lisa Mitchell

As both an art therapist and a marriage and family therapist, I believe that vulnerability, doubt, fear, and uncertainty—feelings most people try to avoid—are essential to getting unstuck in life and engaging in creative problem solving. I try to guide clients to find new approaches to old problems by teaching them how to move beyond “artist’s block,” a state of being joylessly trapped in repetitive patterns and rigid expectations, and how to welcome the type of anxiety around the unknown that creativity invites.

I used this approach with Pam, a 30-something associate director of a nonprofit organization, who came to my art studio after hearing from a colleague about a training on creativity I’d facilitated. Frustrated by her previous inability to get out of her head in therapy, she was intrigued by my alternative, more experiential approach. On the phone, she told me she was seeking therapy because she felt her “inner slave driver,” which had once helped her succeed in managing her career and three children under the age of 12, had begun to dominate her life. “There are endless lists that structure my every waking minute,” she said. “I feel like I’m being worked to death, and there’s no joy in it.” She went on to say that her anxiety and feelings of emptiness had become even more intense since her best friend had died, six months before.

To start our first session, I asked Pam where she thought her inner slave driver came from. She described being 7 years old and having to care for the household and her younger brother after her mother abandoned the family and her father had immersed himself in work. She’d learned how to manage her life with great order and precision, dedicated to the belief that no one could do anything for her that she couldn’t do for herself. But recently she’d begun to question this stance and note the problems it was causing for her, particularly after a confrontation at dinner with her 6-year-old daughter, Gena. That night, after a long standoff in which Gena had refused to eat her broccoli, Pam had finally gotten her to take three rule-abiding bites.

“I thought I was doing the right thing by enforcing the rule,” Pam said. “So when Gena threw up her dinner, I thought she was just being impossible, and I marched her off to bed. But during the night, Gena woke up with a stomach flu. I spent the whole night nursing her and feeling guilty.”
Instead of offering parenting strategies, I told Pam that I wanted to spend our time looking at new ways to behave when her inner slave driver was keeping her stuck in old, rigid patterns, blocking her from other creative possibilities for responding.

Identifying a Creativity Goal

Early in therapy, I try to introduce the idea of flow as a reference point for clients, like Pam, who complain of feeling stuck and blocked. Trying something new and a bit risky, like singing karaoke or canoeing under a full moon, might be a flow experience for some; others might feel flow when expressing deep love or being vulnerable with a partner. In other words, flow happens in moments when time feels unimportant, connection to self and others feels meaningful, or life feels vibrant with newness. For Pam, I suspected that caring for her lifelong friend, Sandy, through the late stages of breast cancer had forced her to let go of her usual rigid mode of being, and thus had been a flow experience.

“When we first talked on the phone and you told me about Sandy,” I said. “I noticed softness in your voice that was different from when you talked about your daughter. I wonder if you see that difference, too.”

Pam replied thoughtfully, “Yes, I was totally different with Sandy. With her treatment, I couldn’t predict how the next day or week was going to go. I had to let go and be vulnerable. Sometimes I wasn’t a pretty picture. I cried a lot and couldn’t find the right words to say to Sandy. But instead of finding an escape, I was at her side when she breathed her last breath. I want that feeling of openness and authenticity in other places in my life.”

The Five Stages of Creativity

As part of my work with clients to help them find flow, I usually spend time telling them about the five stages of creativity—incubating, initial idea, diving in, flexible commitment, and flow—and how each requires tolerating unpleasant experiences of doubt, fear, and anxiety. I offer quotes from various artists to introduce each stage, like Degas’ idea: “Only when he no longer knows what he is doing, does the painter do good things.” I play compositions by Keeril Makan, who said, “When fear arises, I’ve reached the threshold between the known and the unknown. If I’m able to continue composing while tolerating the fear, I will be writing music that is new to me.” I talk about writer Anne Lammott’s take on “shitty first drafts” and choreographer Twyla Tharp’s emphasis on “showing up no matter what.”

Pam was able to see the contrast between these artists’ approaches to creativity and her own approach to life. Still, she had doubts about her ability to change. In response, I told her that sitting with doubt was one of the most creative things she could do right now.

Shrugging she said, “I’ll try.”

Don’t Force a Solution. For our subsequent sessions, I asked Pam to bring in current life examples of feeling blocked so we could identify where in the creative process she was getting stuck and practice getting unblocked. She shared that her 12-year-old son had recently thrown a tantrum when she refused to let him visit a friend on a school night. She said, “I know I handled it wrong because I just laid down the law, and I definitely didn’t feel open or connected to my son.”

I asked her to view the situation with her son as if it were a painting, reminding her that to start a painting, an artist must create space and time for the thoughts to come together.

“OK,” she said immediately, “I’ll just stall and won’t give him an answer right away next time.”

“Try it right now,” I suggested. “See what it feels like to sit and generate options. Look at all the perspectives involved. Just sit with my question, sit with your son’s request. Let it incubate and postpone your answer.”

She sighed and sat quietly, then said, “I can see myself being so much more connected to my son when I sit with the feelings he must’ve been having. It feels totally different.”

Embracing Not Knowing. With each real-life example that Pam brought into session, we began to see that she had difficulty not only with incubating, but also with tolerating the discomfort that comes in the second stage of creativity: Pam’s fear of not being good enough and not knowing if she was doing the right thing wouldn’t allow her to experiment with options in the initial idea phase.

I invited Pam to watch some two-minute animated films on YouTube made by artists. When I stopped one of the films after a few moments and asked Pam to predict what was going to appear in the next frames, she realized it was impossible. Then I asked her to imagine writing her own animated film. Closing her eyes, she described herself and her husband at the start of a trailhead where they liked to hike. She then expressed surprise and delight when her imagination changed her and her husband into birds, flying off and landing in a nest of water, where they turned back into people lying hand in hand in a bed. This spur-of-the-moment internal filmmaking gave her an immediate experience of how an artist can create something without being wed to a definitive outcome. Her surprise to see this internal animation unfold so smoothly tickled her. She looked brighter when she said, “I never just let it unfold, do I?”

I said, “Your old pattern dictates that you either know the outcome or just follow the rule. This is a new way of doing things. Is there somewhere in your life you’d like to try out this letting go and unfolding?”

“I think it’d be helpful when I come home from work,” she said. “Maybe I can just back off and try to see our chaotic evenings as a surprising animated film.”

Fear Is Good. When Pam arrived for her next session, she reported that driving home from work, she’d tried to stay committed to the “letting it unfold” idea, but could only imagine bad things happening when she walked in the door. She expressed doubt about the whole “creativity thing.”

“Experiencing doubt is a good sign,” I said. “It means you’re partnering with your creativity.” To illustrate how anxiety is actually part of the creative process, I asked her to make a scribble on a piece of paper. After she made some messy lines, I said, “Good. Now let’s think of things we could turn your scribble into.” We brainstormed options and chatted a bit about the noisy wild roosters outside my studio, then I invited her to get to work.

She froze. “A minute ago, I had an idea, and now I think there’s no way that I can make my scribble look like the idea. I’m not artistic. It’s not going to turn out.” She’d arrived in her familiar place of feeling blocked.

“Just start with a color,” I said, “and see what it wants to do. Don’t worry about what it’ll become, just start.”

Soon her turquoise blended with purples and a peacock’s feather fanned itself from the back of a bird. Pam muttered as she drew, “I don’t know why I came up with a peacock. I have no idea how to draw the beak, but I absolutely love these colors. I’ve never seen a peacock that looks like this. I’m so madly in love with this bird.”

Pam told me afterward, “I get it, I really do. I have to take the plunge and just dive in. When I do, I have to embrace not knowing and just let it unfold, even if it’s scary.”

I related this to her initial expression of fear. “OK, you’re driving home, you’re scared of the chaos that’ll unfold when you get there, you remember that fear is OK. All you need to do is start with something, like the color in your scribble. What do you want to start with?”

“The feeling of love for my family,” she replied. “Yeah, and I can try to let things go from there.”

“Sounds creative—very open and authentic,” I said.

Mistakes Are Opportunities. Since artists are committed to the act of making art no matter what happens, they have to treat mistakes as opportunities to discover something new, and change direction if something leads them down a different path. Although Pam and I had talked often about the importance of allowing flexibility and vulnerability into her life, it was difficult for her to let go of feeling certain in all situations. But one week, she announced, “I told a board member that I had no idea what the right decision was. I felt authentic and honest, and took the risk of looking completely stupid. It turned out great, though, because instead of making a firm decision right away, we decided to elicit more information. So now, the whole organization has been invited to collaborate. It’s like we’re painting a huge mural together.”

Flow: The Artist’s Reward. Over the next few months, Pam loosened up in many ways, even physically. She became noticeably less stiff in her shoulders and made more eye contact when we talked. It was evident that her inner slave driver was letting go. With her 12-year-old son, she signed up for a photography class, and she started having coffee on Sundays with friends. In one of her last sessions, she told me about a memorable Sunday-morning breakfast with her family.

“My youngest was pouring syrup on her pancakes when the dog came up and bumped her elbow,” she said. “The bottle went flying, and syrup poured all over my daughter. I was horrified and told her to get in the bath quickly before more of it dripped on the floor. While I got the sticky-pawed dog outside, she started the bath water. I went to check on her and discovered she’d gotten in the tub with her clothes on. Instead of scolding her, I hugged her and eased myself into the tub, jeans and all. The memory of us giggling uncontrollably has carried me the entire week!”

This experience exemplified Pam’s new ability to partner with her creativity and open herself to being vulnerable and flexible. She said her anxiety was decreasing with each day, and she actually looked forward to being with her family. No longer checking out on her relationship with them, she felt she’d discovered the creative secret of how to keep checking in.

CASE COMMENTARY

By Jay Efran and Jonah Cohen

Lisa Mitchell’s approach to therapy focuses on cultivating creativity rather than fostering insight. Similar to Acceptance and Commitment Therapy, her methods encourage clients to sit with their distressing thoughts instead of avoiding them or rushing prematurely into action. Specifically, in response to Pam’s request for help with her “inner slave driver,” Mitchell developed a series of creativity exercises designed to increase Pam’s flexibility and self-acceptance. Pam found these methods helpful and reports an increase in spontaneity.

It’s important to keep in mind, however, that there are limits to what creativity training can accomplish. If creativity was truly a mental health panacea, we would see fewer artists, writers, and performers in our practices. Moreover, if it really had a lasting impact on either mental stability or generalized problem-solving ability, it’d be included in required courses at colleges and business schools all across the country. In the current case, it’s difficult to parse how much of Pam’s progress is due to her art therapy exercises and how much is a function of therapy’s nonspecific factors, such as a strong therapeutic alliance and receiving positive reinforcement for taking risks.

Incidentally, personality theorist George Kelly wrote that creativity cycles always involve two phases: loosening and tightening. Without the first, there’s no novelty; without the second, there’s no productivity. Thus, the most crucial skill may be learning to shift easily between these two phases—from open-ended brainstorming to useful synthesis. In this context, Pam’s willingness to solicit information from other members of her organization can only be considered a partial success. A full victory would require that she also be able to collate and make effective use of the feedback she receives.

Instead of endorsing Pam’s metaphor about fighting her inner slave driver, we would have encouraged her to fully embrace her obsessive, perfectionistic style. Such characteristics are legitimate and valuable aspects of her personality—friends to be courted, rather than enemies to be vanquished. After all, without her drive and attention to detail, would Pam have had the same degree of success in business and child rearing? The truth is that each of us falls somewhere on the obsessive-impulsive spectrum, and every position on that continuum brings benefits and headaches. Furthermore, as the developmental research shows, our fundamental temperament traits have large genetic loadings and are likely to remain for life, regardless of how many years we spend in therapy or how many improvisation exercises we complete. Therefore, the trick is to appreciate our characterological quirks and learn how to put them to good use. As we tell our clients, it’s usually easier to ride the horse in the direction it’s going. Of course, Pam needs to remind herself to go off duty once in a while. Yet she should also take time to celebrate the gifts provided by her often ambitious, single-minded nature. This is true self-acceptance.

AUTHOR’S RESPONSE

While artists, writers, and performers may know a great deal about being creative in their chosen art form, they are often not aware of how to apply the creative process to other aspects of their lives. They can benefit greatly from learning to see relationships, emotions, and problem solving in the same way that they see their art. Along the way, they can also learn how to tolerate doubt, uncertainty, and other unpleasant emotions in service of an expanded experience of life.

While it’s difficult to say whether Pam’s single-mindedness was due to genetic loading or other factors, it was clearly taking a toll on her relationships. In the process of learning to tolerate the uncertainties that come with delayed decision-making, she was able to soften in her way of being with others and open herself to more creative risk-taking. Eventually, she discovered that she didn’t need to fight her inner slave driver, just understand that this powerful aspect of herself was blocking her access to her own creativity.

Lisa Mitchell, MFT, ATR, writes and trains on the topic of creativity and therapy. She works with clients and therapists to partner with their creative process in her private practice in Sacramento, California, and blogs at Inner Canvas. Contact: lisa@innercanvas.com.

Jay Efran, PhD, professor emeritus of psychology at Temple University, is the coauthor of Language, Structure and Change: Frameworks of Meaning in Psychotherapy and The Tao of Sobriety. Contact: efran@temple.edu. Jonah Cohen, MA, a doctoral candidate at Temple University, is currently researching social anxiety at the department’s Adult Anxiety Clinic.

Wearing Your Heart on Your Face

The Polyvagal Circuit in the Consulting Room

By Ryan Howes

As we all learned in school, we have two options in the face of perceived danger: fight or flight. But that was before neuroscientist Stephen Porges, author of The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation, undertook his research into the relationship between human physiology and social engagement.

Porges’s work—which noted researcher Paul Ekman called “a truly revolutionary perspective on human nature”—dramatically broadens our understanding of the sympathetic and parasympathetic systems, and explains how our bodies and brains interact with one another to regulate our physiological states. However, what may be more pertinent to therapists is the extent to which our autonomic nervous systems influence long-term issues with intimacy and trust. In the interview that follows, Porges offers some research-based insights into how therapists can more effectively convey safety to clients and clarifies the evolutionary roots of anxiety, depression, and trauma.

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RH: Can you explain your Polyvagal Theory in simple terms?

Porges: It’s hard to make it simple, but let’s try by starting with what we’ve all learned about the autonomic nervous system. It’s a pair of antagonistic systems: the sympathetic supports mobilization, and the parasympathetic supports immobilization, usually associated with relaxation, growth, and restoration. In the past, we tended to believe that stress responses were, in general, vested within the sympathetic nervous system’s capacity to support fight-or-flight behaviors. But there’s another defense system, unrelated to the sympathetic nervous system and dependent on the parasympathetic nervous system. The mechanisms and adaptive function of this defense system are impossible to understand from the paired antagonism model. The parasympathetic defense response is mediated through a vagal circuit producing a behavioral shutdown such as fainting or, from a clinical perspective, dissociation. This defense system doesn’t fit within the fight-or-flight model. Nor does it fit within the view that the vagus, the major nerve in the parasympathetic nervous system, mediates calmness and induces resilience and health.

RH: Your work suggests that our autonomic systems are better thought of as hierarchical, rather than competing.

Porges: Right. The vertebrate autonomic nervous system has changed through stages of evolution, and the human autonomic nervous system shares several of these autonomic circuits with more ancient vertebrates. Functionally, our autonomic nervous system is composed of three phylogenetically organized subsystems. We utilize our newest systems first, and when they don’t work, we recruit older ones. In terms of evolution, the newest autonomic circuit is a uniquely mammalian vagal circuit, which inhibits the heart rate by placing a tonic inhibition on the heart’s pacemaker. This circuit also inhibits sympathetic activity. The brainstem areas controlling this neural pathway coordinate the nerves controlling the muscles in the face and head. So people are literally showing their heart on their face. That’s because humans are social beings who have to convey to one another that we’re safe to come close to, to hug, and in some cases, to have sex with. To convey this message of safety, we utilize the newest vagal circuit to down-regulate our sympathetic defenses and present cues of safety when it’s appropriate. While the face is a crucial vehicle for this, the voice also plays an important role in conveying a physiological state of calm. If the voice has a higher-pitched frequency, it’s saying, “Don’t come near me.”

The thing to bear in mind is that the vagal circuit is both expressive and receptive. That’s why you feel calmer when I use a soothing, prosodic voice. When the vagal circuit is working, our middle-ear muscles change our capacity to hear predators or low-frequency sounds. Middle-ear muscles, similar to the muscles of the face, are regulated by the brainstem area that controls the mammalian vagal circuit. Typically, when there’s something in the environment that threatens us, we turn off the vagal circuit, because it inhibits our ability to mobilize: it gets in the way of moving to fight or to flee.

RH: That’s because it’s the vagal system that makes us freeze, right?

Porges: Yes, but there are two vagal systems. The root of the Polyvagal Theory is the recognition that in the absence of the ability to fight or flee, the body’s only effective defense is to immobilize and shut down. This can be observed as fainting or nausea, both features of an ancient vagal circuit that reptiles use for defense. However, unlike the uniquely mammalian vagal pathway, these vagal pathways are unmyelinated, and are only effective as a defense system when the newer circuits, including the sympathetic nervous system, are no longer available for interaction and defense. Our reptilian ancestor was similar to a turtle, and the primary defense for a turtle is to immobilize, inhibit breathing, and lower metabolic demands. Although immobilization may be effective for reptiles, it can be life-threatening for mammals, and for humans it can lead to states of dissociation. The Polyvagal Theory provides a way of seeing how the organization of our nervous system can shape our understanding of clinical disorders and issues, enabling us to see symptoms like dissociation not as bad behaviors, but as adaptive reactions to cues in the environment that trigger our physiological responses to perceived dangers.

Think about it this way. When you want to calm a person down, you smile and talk to them in a soothing way. The nervous system detects these cues and down-regulates or inhibits the sympathetic nervous system. But when the sympathetic nervous system is activated as a defense system, it turns off all those social-engagement behaviors. Clinicians are aware of that. But what they often don’t understand is the role of the vagal system in shutting down as a defensive strategy in response to a life threat. When someone is immobilized, held down, or abused, the vagal system is triggered, and they may disassociate or pass out—or perhaps drop dead or defecate. It’s an adaptive response.

I often talk about immobilization with fear and contrast it to immobilization without fear. The mouse in the jaws of a cat is immobilized with fear. The mouse isn’t voluntarily playing dead; it’s fainted. But someone in the embrace of a lover, parent, child, or friend is immobilized without fear.

RH: We might call that stillness, or peace.
Porges: Right, you’re still, but you’re being present. For reptiles and more primitive vertebrates, the primary defense system was to disappear—to immobilize, stop breathing, and look like you’re dead. For mammals, immobilization is a risky business. We have to be selective about whom we can feel still, calm, and comfortable with.
Many clients have difficulty feeling comfortable in the arms of another. They can’t immobilize without fear. If you go through their clinical histories, you’ll find that many were severely abused and had experiences of being forcedly held down. These experiences of forced immobilization trigger fear responses and shutting down. Those who survive these experiences don’t want to be immobilized and find it difficult to be held and calmed, even by people who are trying to be helpful. This response is often expressed as anxiety and a need to keep moving, which is a functional defense to a fear of immobilization. Often individuals with a history of immobilization with fear will adaptively become anxious and go into panic states to avoid this immobilization state. This is a problem many therapists see in their practices.

RH: What are the practical implications of Polyvagal Theory for clinical work?

Porges: It heightens our appreciation of the role of creating safety in therapy. For example, our bodies, physiologically, are extraordinarily sensitive to low-frequency sounds. We, like other mammals, interpret these low-frequency sounds as predatory. If your clinical office is bombarded with sounds from ventilation systems, elevators, or traffic sounds, your client’s physiology is going to be in this more hypervigilant defense mode. Likewise, if you sit some people in the middle of the room away from a wall, they may become hypervigilant and concerned with what’s going on behind them. If we’re not safe, we’re going to assume that neutral faces are angry faces. We’re going to assume the worst because that’s what our nervous system tells us to do. As vertebrates evolved into mammals, they had to interact with other mammals for survival. They needed to detect the social cues and identify when it was safe to be with another mammal. Thus, vocalizations in social contexts are less about syntax and language and more about the intonation conveying emotional state. Again, this is critical in therapy because the intonation of voice conveys more information about the physiology of the client than the syntax.

RH: In other words, how you’re saying something means more than what you’re saying.

Porges: Absolutely. When you were an undergraduate, what were the lectures that put you to sleep? Was it the college professor who was off in space, who basically read from notes and had no prosodic features and no engagement? Social communication has little to do with syntax and a lot to do with intonation, gestures, and a cluster of behaviors we would call biological movement. The face is moving along with the voice and hand gestures. The behavioral features trigger areas of our brain outside the realm of consciousness and change our physiology, enabling us to feel closer and safer with another. Good therapy and good social relations, good parenting, good teaching, it’s all about the same thing—how do you turn off defensiveness? When you turn defense systems off, you have accessibility to different cortical areas for more profound understanding, learning, and skill development.

Ryan Howes, PhD, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs for “In Therapy” at Psychology Today. Contact: rhowes@mindspring.com; website: www.ryanhowes.net.

By Rich Simon Anybody who’s been making a living as a therapist in private practice for a while will readily tell you that things aren’t what they used to be. Sure, incomes are down. Reimbursements aren’t what they used to be. Referral sources have changed. It takes more effort and marketing savvy to keep a practice afloat. But many practitioners still carry on as if it were still 1980-something and their potential clients are fundamentally the same as those who sought therapy three or more decades ago.Read more …